GW1-2022-05341_Well Construction - GW1_20220530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Clint J Babbitt ECEI M D 14.WATERZONES'
Well Contractor Name FROM TO DESCRIP1710N
NC-3556-A MAY 3 0 2022 ft. fL
tr. iL
NC Well Contractor Certification Number t i^,rl PMC?zGCk%*j U
IS.OUTER CASING Car multi-cased wells OR LINER if a llcuble
AAA Sweetwater Well & Pump, Ind}JUBOG °�t T° DIAMETER
T,° rL.TERtAL
iL IL
in.
Company Name
Cg I W 1� 16.INNER CASING UK
2.Well Construction Permit#: � FROM TO DIAME ER TIRCICi&SS MATERIAL
List all applicable trell construction permits(i.e.UIC,County,State,Yariame,etc.) r ft. ft 6 114 to' SDR-21 PVC
3.Well Use(check well use): fL ft. in.
17.
Water Supply Well: FRONTREE TO DIAMETER I SLOT SIZE I THiC"ESS I MATERIAL
Agricultural OMunicipal/Public It. ft. im
Geothermal(Heating/Cooling Supply) �idential Water Supply(single) fL ft, can,
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
irri ation FROM TO MATERIAL ERIPLACEMENT METHOD&A&FOfINT
Non-Water Supply Well: 0 20 to Bentonite Screened
Monitoring Recovery ft. ft.
Injection Well:
fL ft.
Aqudfer Recharge OGrotmdwater Remediation
19.SAND/GRAVEL PACK irapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEnIMMETHOD
Aquifer Test OStormwater Drainage % ft
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if uccessa
Geothermal(Heating(Cooling Return) Other(explain under#21 Remarks) FROM To DEscRHnTON rntor,harda soturock a ere etc
ft ft.
4.Date Well(s)Completed: /Z Wen HW ft. fL
5a.WenLoC2tlo & ft
_. ft. n
F ility/Own/eer}NameO Facility ID#(ifapplicable) ft ft.[[[[U� ft. ft.
Ph sical Ad s,City,and Zip ft. ft.
t 21.REMARKS
County Parcel Identification No.(PiN) Grouted On: a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one Iattlung is suflicicat) 22.Certification:
• N W t�
6.Is(are)the wells) rmanent or OTemporary rgnatum of C tified Well Contractor i Date
By signing this form,I hereby certfi•that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or 13NIO with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of dais record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site tars cc^
construction,only 1 W 1's ceded Indicate TOTAL NUMBER of wells construction details. You may also atr�adtyct ?
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 00 (D-) 249.For All Wells: Submit this form within 30 days of mow:
For multiple wells list all depths if different(example-3@200•and? I00) construction to the following:
10.Static water level below top of rasing: (ft.) Division of Water Resources,Information Pracessing T aG
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-161 i
I I.Borehole diameter. 6 (in.) 24b.For Inlecdon Was. In addition to scniing the fort 10:23-
Drilled above,also submit one copy of this form withm`-38-da)s or s
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injecti it Cas=aa`
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 270%4ti C
Timed 24c.For Water Supply&InjectionWelk �.s_� �-
13a.Yield(gpm) � Method of test:
the addresses) above, also submit one copy of tom:
13b.Disinfection type: CC" Amount: completion of well construction to the corny bl,
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources s- -